By Kimberly R. Powell, PhD, RN, CNE; Gregory L. Alexander, PhD, RN, FAAN, FACMI
Powell, K. & Alexander, G. (Summer, 2019). Mitigating Barriers to Interoperability in Health Care. Online Journal of Nursing Informatics (OJNI), 23(2). Available at http://www.himss.org/ojni
Achieving interoperable health information exchange (HIE) is a critical component of health care delivery system reform. When information is able to flow seamlessly across the continuum of care, there are direct implications for efficiency gains and more importantly, health outcomes. For example, interoperability improves clinical decision making through timely and complete access to information, evidence-based guidelines are more accessible, and care is more person-centered when patients and caregivers are empowered by having access to and control over their health data (Walker et al., 2005; Zhou et al., 2014). Despite these gains and widespread agreement among policy makers and researchers that interoperability is necessary to deliver high-quality care, engagement in HIE remains low (DeSalvo, Dinkler, & Stevens, 2015; Holmgren & Adler-Milstein, 2017). Specifically, U.S. hospitals are lacking the infrastructure necessary for health information to be integrated into the electronic health record without manual effort, a key capability of interoperability (Holmgren, Patel, & Adler-Milstein, 2017). Without integration capability, there is no way to ensure providers have comprehensive clinical data as patients move across different care settings. Improving interoperability requires a mix of strategies including realignment of economic incentives and mitigating barriers impeding the secure exchange of electronic health information.
Recognizing the importance of interoperability, Congress has passed numerous pieces of legislation to promote adoption and to establish a legal framework guiding the use and exchange of health data. In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed to drive adoption and use of HIT by authorizing the Centers for Medicare and Medicaid Services (CMS) Incentive programs (US Senate in Congress, 2009). The Patient Protection and Affordable Care Act (ACA) enacted in 2010, incentivized HIE through new reimbursement policies and value-based payment programs (US Senate in Congress, 2010). Most recently, the 21st Century Cures Act, signed into law December 13, 2016, addresses the use and exchange of health data through HIE and sets a legal precedent preventing information blocking, a serious threat to achieving interoperability (US Senate in Congress, 2016). As required by the 21st Century Cures Act, the Office of the National Coordinator (ONC) for Health Information Technology issued a notice of proposed rulemaking to improve the interoperability of health information technology and implement the information blocking provisions of the Cures Act. The proposed rule closed for comment on June 3, 2019 (HealthIT.gov, 2019).
Restricting patient access to the medical record and growing concern about providers and electronic health record (EHR) vendors knowingly engaging in business practices that interfere with HIE are limiting interoperability. Such “information blocking” is thought to occur in an attempt to achieve financial gains by charging fees, making exchange of information cost-prohibitive or in an attempt to control referrals thus enhancing market dominance on the part of the health care provider or health system (HealthIT.gov, 2019). For example, in a recent national survey of HIE leaders, respondents indicated that vendors routinely deploy products with limited interoperability, charge high fees for HIE, and make third-party access to standardized data difficult (Adler-Milstein & Pfeifer, 2017). Based on this evidence as well as anecdotal reports of similar activities reported to ONC, CMS and ONC proposed new rules to “increase choice and competition while fostering innovation that promotes patient access and control over their health information” (Department of Health and Human Services, 2019, p. 1).
Information blocking occurs when providers or developers knowingly engage in practices likely to interfere with exchange or use of electronic health information, leaving interoperability unprotected. Prior to enactment of the Cures Act, information blocking was not well defined or understood (US Senate in Congress, 2016).
In addition to deliberate attempts to block HIE, other systemic barriers to interoperability exist despite attempts to address them via the HITECH Act and other reforms. One major barrier is lack of coordination among different facilities/health systems participating in or facilitating HIE (HealthIT.gov, 2019). Often these coordination problems stem from technical or practical challenges. For example, inconsistent implementation of technical standards resulting in EHR systems that do not integrate information among systems and have no way to integrate external information received from a third-party intermediary. Another barrier to interoperability has stemmed from divergent policies related to privacy, security, and trust that govern how electronic health information is exchanged or used. These reasons could explain the lag in adopting technologies like patient portals in post-acute settings such as nursing homes (Powell, Alexander, Madsen, & Deroche, 2019).
Overcoming barriers to interoperability will require both near and long-term strategy. In the near term, establishing a clear definition of information blocking and direct enforcement of the policies prohibiting it will open up road blocks which historically had brought HIE to a screeching halt. Long-term strategies rely on a culture shift whereas interoperability is driven by transparency, value, and innovation.
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Kimberly R. Powell is a registered nurse, certified nurse educator, and assistant professor at the University of Tennessee, Knoxville College of Nursing. Her area of scientific interest includes health information technology and gerontological nursing with an emphasis on self-management of chronic conditions by patients and family caregivers. Dr. Powell is currently a post-doctoral fellow, mentored by Dr. Gregory Alexander at the University of Missouri, Sinclair School of Nursing.